A40 301s
�
p,00tt�atlo� o�e�,; 7- �r - o'
. �so �� .
�'i�T
�
����43
Persoe Cou�rtv Heaith Deoardn4trt
Errviroemerrtai Heaitl� 3ectio�
- :�. • �• - =:�� ��
Tax Mau �k /� � b
�qresi #: 3 D /
0
�'d ���� ,o�
� �� �
�i /
IF THE INFORMATfON IN THE APPLICATION FOR�AN IMPftOVE�AENT PERMIT 13 FAL31Fl�. Cli�ANGED. OR THE SiTE IS
ALTER�. THEN'THE 1MPROVEi4AAEi�11' PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALlD.
,� Hortm Pt�at� . (����� �A�x � �"Y�� ' �
.S � � � S- 6 �- w�o �a°
Bt�s Pho�e: " " �►-w C , �- ) ,�) J
Z� Naate and address of curroat owr�er: �`"-� . ,
� s� s +�.��s •�i.
..0 1� � , � � � 3
3) Propariy Descriptlon: �ot � l.� �- Ta,�tda �' 1 De
D'vec3tons ba tha p�ope:ty pt�tding road rmmes and nurttbers� ��-a�r �, '
4) Ptoposad Uas and Stntct�rs Des�ripttan: anawet ead� af thn fanowing que�o�m:
ai ProPo�sdE�E�ng❑ : ..<.,:,: r
b) Stldc Su�t q Moduiar Q, St�le Wtde �, �auble Ylrtde GY ,,-
� Number af Bedtoomx 3 c� Ntunber of ccapants� ar peopls to be setve� �
e) Baaema�rt Yea Q No 0�1i yea. � oi baaement ttxt�uex
• t� Gacbage DiapOsa� Yas 4 Plo� .
gI Qh�nsionsot Ptoposed Str�ce: VVidtt�: 2 g Daplt� s°
�% �' �PPhf ZjIP� Ptivaie 0'�new a oc aod�ln9 �. Pub6c q�xu�l 0. Spdn� 0.
Are any weib on adJoining property? Yas 0 No 0 lf yes, focatton
6j Plwse Indtcad O�aited Syatam 1jIPe: (sya�ams can be � in ard�r of Y�' P�)
✓Coave�tlonal I�d C�anv�ntloml _A�t�tlw __,_Icu�oYaflv�
Otl�r (sp�: .
CLEARLY STAKE ALL CORNERS ANO 11NES OF THE PROPERTY.
STAKE THE CORNERS OF ALL PROP08ED STRUCTURES.
PLEASE ATTACtI SUFtVEY PU1T OR SRE PLAN TO 7HIS AP4t.tCAT10N
i herobY mske a�6� te the Person Cattity l�kelth Departrne�t ior a a�e avah�tlon toc ths aFsiie sawa�a disp�al ay�n �
the above�desaibed propehy. l aQree ti�at the co�t,ents of this appi�ion are true and t� ttta tna�dmtnn faa�na io
pbacsd on ttte pr+o�Cty. 1�uu�nd ittha s�e b altec�ed aths inbended uu ct�tpes. the pecm� st� becoms invald-1 tntd�ta
tltat as app�ant� I am t+espo�ie fo� ida��ifj�ng and rtmddn9 Pt'oP�Y �, �mera and maldng ttys ai�e a�s far �
pecaonnd af the Person Caunty Heaqh Departmatt to condud tt�ir avaN�atlaas. l tatdecstand tl�at 1 am t� �' �1�9 �
H�Ith 0 If my prop�i�a any wetlands as desip�ed bl1 ��mY �Ps ��-
�—�1 - o0
or l.�al Re�xasaNative . oatie
, � - --.
• _ � , ---- ''_ _ .- �+
.� .
� , � �
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
r��P�: �4a �� v��
ZoNng _ Townsdip ��Li;t � I U G f
�P��: mm FFa,c�K�'ns .
���,,,: � 1� 2 F Rd D�-kSt�nLccnc L pt,t�mv► Orit�t Lat on�
s��y�,:4�a.IC�i d5c Ruc�S s.a��: � �
Im�rovement Permit .
A building pennit cannot be issued with oniv an Imarovement Permit �
New �Repair _ Add'fion _ Type of Stnu��re mff Water Supply ��� �- � t I �
# of Occupants� �# of Bedrooms � Othec_ • .
Basement? , j��Basement Fixhires? �[,,.� .
} Projeded Daily Flow:c7��g.p.d. Permit Valid For. �'Five Ysars 0 No F�cpiration
Proposed Wastewat ystem Type: � laraJ �� !�n r10 VGL�� V�
Pump Required? �ires No C�r 2�Pf}ac 2
��-�� t � Or� Ca n%u�, v yc�t�rn �I- (Z�-Pa.i r ho�U e� bztn FIa���
Permit Condi�ons: -,
(�n6��c.� Oo N(�T �n5-��� anv �t aF Sv,���m i n �i&tv.rbcd area.
Owner or Legal Rep tive n re:
� �y' f Date: `�� Z
Authorized State Agen� � Date: �a� `��
The tssuence of thls perm by the Heaith Departmerrt in no way guarantees the issuanca of other permtts. The pertnit .
holder is responsible for checking with appropriate goveming bodies in meeting their requirements. This � aite is _
aubject to revocation if the site plan� plat, orlhe i�tended use changes. The Improvement Permit shall not be
affected by a change in ownership of the stta. Thts permtt ia subject to compliance with the provisfons of the
Laws and Rules for Sewage Treatment and Dlsposa� Systams of the North Carolina Administrativa Code.
Authorization To Construct Wastewater Svstem (Reauired for Build[nst Permit)
Type of Wastawater System �n n o Ja-�� ��- Wastewater Fiow: � a.p.d. •
FadlityType: m�b,��C. �0()'l� . New�RepairOExPans(on�
Basement? 0 Yes o Basement Fbdures? 0 Yes o � au ( ���x � m�-� [y
Wa���#er Svstem ReauiremeMs � O0`�`� � F
(.�Pf��K) � �Tande m �"uc�
Sep�c Tank Size: i/�� gallons Pump Tank Size: ,`,�_ 9�lons To QS�' �� Fo r o�dci c%�na I
�/ �Ve,� �vcr
Total Trench Length:� feet Maximum Trench Depth: ,$. inches Aggregate Depth' l� in. �y�m � n
no �,,S5-��,an
�ax3mum Soii Cover. � inches Trench Separatlom Feet on CeMer . �6,p�,I fOc,�7 0.i��
OcherD� I�C�T PL�C� �(Z,Z�-� OU�2 F1-N)! P A'2, (� F
PeRnit Expiration Oate: a 0 I�d�� .�� P�S C� Y S T� m�
Authorized State Agent: Date: 0�o��� �
The type of system perm d O does O does not dlffer from the type specified on the application: I accept �
the speciftcationa of this permit � �
OwneNLegal Representative Stgnature: Dabe: Z� �
PCHD, rev/ 10/12/99
0
�
4
'_" . . . �� ". .
_ l. I,,�S
s�a�e:
PCHD. rev. 10/�12/99
A
Appllcatton #: ______
Tax Map #: �
Parcel #: 3 Q �
Person �.County Health Department ,
Environmental Health Section
SITE SKETCH .
� �t,K�id c �t`45 �
��� �Y �Q�K � � Sub ivision/Section/Lot#
.Appticant's ame �
- �d /aB � o�
Authorized State Agent Date .
System components represent approxlmate contours only. The contractor must flag lhe system
rlor to be innln the lnstallntlon to tnsure that ro er rade is maintained
�
, ' Person County Health Department
Environmental Health Section ' -
Tax Map #: �9� Parcel #: �va �
Zoning: Township: �/at QiJtr
Subdivision• baKri c�it fteres Section: Lot: �J
Applicant: �m my }-fa� k i� S
Location: Nc.c-FF %ZacLd
�peration Permit
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
w� Lrunc��nr�n�i
Authorized State Agent
lb -��—oc�
Date
Person County Heafth Department
Environmental Health Section `
Zoning: Township: F/ u�t R.► � c, r
Subdiviston: �'i.�Cri � �}G��" Section: Lot:�,_
Appiicant: �c►'v`►^ �c,v ',�,
Location: �u F��.caa d
Operati�n Permit
1. LOCATION AND SEPARATION DISTANCES /
A) System meets .1950 setback requirements V No� an �o-T� 3
B) Distance from system to any welis �i�i.�$ c�T� �cti
C) Distance from septic tank to foundation a�_
D) Distance from system to property lines 10 o I�. S
2. SEPTIC TANK '
A) Visually inspect the exterior walls and top of the tank,�, �
B) Visually inspect the interior wa11s, b , tee, filter, riser, lids, air vent,
bottom, and water tight outlet �
C) Date of tank manufact�re (c-Ilv-�o
D) Tank serial number 5�� 14 Z
E) Liquid capacity of tank �t�UD gallons
3. SUPPLY LINE TO TRFNCHES
A) Grade �/ (1/8 inch per foot minimum��L
B) Material supply Iine is constructed from 9
C) Diameter
D) Length S' �
E) Distance from tank to drainfield/distribution device N��
4. DISTRIBUTION DEVICE(S)
A) Type N / R .
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) is the device on a level foundation
E) �oes the device pertorm according to its design specifications
F) Record the inlet and outlet elevations
5. NITRIFICATION FIELD mo,,�� � Z
A) Trench depth I$ maX inc�es -
B) Trench width 3�—inches ,
� C) Distance between trenches �
D) Number of trenches '
E) Length(s) of trenches �o� 9 s�� Ro,� /1��
F) Aggregate depth ��A inches
G) Aggregate matenal and size /ii' �- Z- L•� Y
H) Record septic t utle•t� levation
I) Trench grade ,� �/ (< 1/4" per 10')
J) Step downs �
a. Minimum of 2' of undisturbed ea
b. Proper rise over step d n�_
a Solid pipe used �
d. Elevations of step downs �(Record elevations and show on as built)
See "as built" plan on attached sheet.
�k
� PCHD, rev. 10/12/99
' � � � � PERSON COUN-TY ENVIRONMENTAL HEALTH
9- n� PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Mapl1: �'1 O Parcel # �� �
ZoNng Township ��ix-� 1�) VC'`
Applicanx �rM M � �a,(�K I ((tiS
Locatlon• J�.C. P�2m�-T
Subdivtsion•
Sectton• Lot
Type of Water SupplV:
ReQuirements•
Site Approved by S �C
Grouting Approved by _
Well Log o �
Well Tag .� �0 3 r
Air Vent � s co 3'
Hose Bib �/ Rs' rd � �
Concrete Slab �/�S la
Wefl Permit
� Individual Community Public
0
QL
r-
��
06
,
. �,.__ l�.
�.. . -. �'� �� ��i►'J
,
Date: �a � 1 6�
**See Attached Site Sketch**
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Welis must be �at least 25 feet from any building foundation.
Other conditions: ����-�� � b�`�� �� n�m �t
PCHD, rev. 11/29/99
�
.
�
PERSON COUNTY ENVIRONMENTAL HEALTH
WELL LOG
Date: 1���1-od '
�WIleI:_�nr►i t
Location%Directions:
J
Subdivision Name: __ o��%�S2
Drilling Contractor: � �
�
SR#
Lot # �3 -
WELT. CONSTRUCTION V
Distance from Nearest Property Line I v Distance from Source of
Pollution ( G �
Total.Dep.th: /�� Ft. Yield: �� GPM Static Water Level a.r" Ft.
Water Bearing Zones: Depth t361 ��[. Fc. Fc. Fc.
Casing: Depth: From 6 to��Ft. Diameter: Inches
TYPE: Steel � Galvanized Steel
If Steel, does owner approve: Y�s No
� � Weighc: Thickness:�, '� Height�Above Ground: /�-/ Inches
Drive Shoe: Yes ✓ No .
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason;
Grout: Type: Neat Sand/Cemen[ / Concre[e
Annular. Space Width � Inches .
Water in Armular Space: Yes No
_ .. Method: Pumped � - Pressure � Poured � � - � � � �
Depth: From O to �, O Ft. �
Materials Used: No. Bags Portland Cement Weight of .1 bag lbs.
If mixture (sand, gravel; cuttinas) - Ratio: to
ID Plates: Yes � No � � �
� 4 x 4 slab Yes i No
I HEREBY CERTIFY THAT THE ABOVE 1NFORMATION IS CORRECT AND THAT
THTS WELL WAS CONSTRUCTED IN ACCORDANCE H REGULATIONS SET
FORTH BY�THE PERSON C�UiJTY HEALTH DEPART�IMV ��V�!
�
�
�e
;?